Asthma and respiratory dysfunction among urban, primarily Hispanic school children

A screening program identified children with poorly managed asthma or respiratory dysfunction. Children in grades 2-5 in all Passaic, New Jersey, schools were eligible for screening with questionnaires and a biometric test. Those with risk factors or failed biometric screening were referred to primary care providers. Of the 6,579 eligible children, 3,657 (56%) had parental questionnaires returned and 3,834 (58%) were biometrically screened. Over the 4-yr study period, 6-22% of children were previously diagnosed with asthma. Approximately 20% of children demonstrated peak flow measures <75% of predicted values. Predictors of a prior diagnosis of asthma and a medical treatment plan for asthma management were health care coverage and ethnicity. Predictors of peak flow test failure were the presence of roaches and mold in the home, pesticide use, and a family member with asthma.     

Evaluation of Community Action Against Asthma: a community health worker intervention to improve children's asthma-related health by reducing household environmental triggers for asthma.

This article describes the evaluation of a community-based participatory research (CBPR) community health worker (CHW) intervention to improve children's asthma-related health by reducing household environmental triggers for asthma. After randomization to an intervention or control group, 298 households in Detroit, Michigan, with a child, aged 7 to 11, with persistent asthma symptoms participated. The intervention was effective in increasing some of the measures of lung function (daily nadir Forced Expiratory Volume at one second [p = .03] and daily nadir Peak Flow [p = .02]), reducing the frequency of two symptoms ("cough that won't go away," "coughing with exercise"), reducing the proportion of children requiring unscheduled medical visits and reporting inadequate use of asthma controller medication, reducing caregiver report of depressive symptoms, reducing concentrations of dog allergen in the dust, and increasing some behaviors related to reducing indoor environmental triggers. The results suggest a CHW environmental intervention can improve children's asthma-related health, although the pathway for improvement is complex.     

上海市社区就诊病人自报家庭医生签约现状与人口学特征分析

目的 了解上海市家庭医生签约现状,探讨社区就诊居民人口学特征与签约的关系.方法 采用自行编制的调查问卷,选取5个社区卫生服务中心拦截式调查社区就诊居民,共计调查1 021人,回收有效的959份,回收有效率为93.9％.结果 调查居民平均年龄（59.91±14.30）岁,其中50岁以上占81.2％,男性348人（36.3％）,女性611人（63.7％）,居民自报家庭医生签约率为30.2％,多因素非条件Logistic回归分析发现女性（OR=1.44,95％CI （1.04～2.00））、年龄大于70岁（OR=2.17,95％CI（1.13～4.14））以及长期服药（OR=2.66,95％CI（1.56～4.54））的人群更倾向于签约家庭医生.结论 病人自报家庭医生签约率尚低,在推广家庭医生签约制时,应在扩大宣传、完善基本配套政策措施上,重点从女性、70岁以上人群及长期服药人群入手,提高居民签约率,以带动其他居民.     

Methods and issues in conducting a community-based environmental randomized trial

The environment is suspected to play an important role in the prevalence and severity of asthma in inner-city children. This paper describes the implementation and baseline data of an inner-city community-based participatory research clinical trial designed to test the effectiveness of a pollutant and allergen control strategy on children's asthma morbidity. Participants were 100 elementary-school-aged children with asthma, graduates of a school-based asthma education program in East Baltimore. The intervention for half of the randomly assigned families consisted of environmental control education, allergen-proof encasements, pest extermination, and a HEPA air cleaner at the beginning of the study. Controls received the same at the end of the study. Participants visited a clinic for questionnaires, allergy skin testing, spirometry, and blood sample at baseline and 12 months. Home environments, NO(2), O(3), airborne particulates, and allergens were evaluated at baseline and at 6 and 12 months. Asthma morbidity and adherence was assessed quarterly. Collaboration with the community proved very beneficial in creating a study design and procedures acceptable to an inner-city community.     

Feasibility of school-based spirometry screening for asthma

To determine the feasibility and value of spirometry in school-based asthma screening, spirometry testing was coupled with parent questionnaires in a school-based asthma screening project. Children in grades five to eight of the Catholic school system in Rochester, Minn., performed spirometry with coaching and data acquisition by nurses trained for this activity. Most students completed three tests. For each student, the best test was selected for interpretation. Tests were considered technically unacceptable for screening purposes if the FEV1 was less than 85% and the curve showed evidence of cough, delayed start, poor initial effort, incomplete effort, or non-reproducibility. Students with acceptable tests and FEV1 < 85% as predicted for age, race, and BMI were classified as appropriate for referral for further evaluation of potential asthma. A sensitivity analysis was conducted using different FEV1 thresholds for referral. Children (119, 17.6% of all) with known asthma based on parent-completed questionnaire were not considered for referral. Of the remaining 557 students screened, 535 had technically acceptable tests, and 498 had normal spirometry performance. Using a threshold for referral of FEV1 < 85%, 37 children were candidates for referral for further evaluation of potential asthma. Only four (11%) of these also had questionnaire responses that made them candidates for referral. School-based spirometry screening for asthma is technically feasible but there is little overlap between those who are referral candidates based on spirometry data and those who are referral candidates based on parent-reported symptoms on screening questionnaires. Without further study, spirometry cannot be recommended for school-based asthma screening.     

Asthma in Inner-City Children at 5–11 Years of Age and Prenatal Exposure to Phthalates: The Columbia Center for Children’s Environmental Health Cohort

Background: Studies suggest that phthalate exposures may adversely affect child respiratory health.Objectives: We evaluated associations between asthma diagnosed in children between 5 and 11 years of age and prenatal exposures to butylbenzyl phthalate (BBzP), di-n-butyl phthalate (DnBP), di(2-ethylhexyl) phthalate (DEHP), and diethyl phthalate (DEP).Methods: Phthalate metabolites were measured in spot urine collected from 300 pregnant inner-city women. Children were examined by an allergist or pulmonologist based on the first parental report of wheeze, other respiratory symptoms, and/or use of asthma rescue/controller medication in the preceding 12 months on repeat follow-up questionnaires. Standardized diagnostic criteria were used to classify these children as either having or not having current asthma at the time of the physician examination. Children without any report of wheeze or the other asthma-like symptoms were classified as nonasthmatics at the time of the last negative questionnaire. Modified Poisson regression analyses were used to estimate relative risks (RR) controlling for specific gravity and potential confounders.Results: Of 300 children, 154 (51%) were examined by a physician because of reports of wheeze, other asthma-like symptoms, and/or medication use; 94 were diagnosed with current asthma and 60 without current asthma. The remaining 146 children were classified as nonasthmatic. Compared with levels in nonasthmatics, prenatal metabolites of BBzP and DnBP were associated with a history of asthma-like symptoms (p < 0.05) and with the diagnosis of current asthma: RR = 1.17 (95% CI: 1.01, 1.35) and RR = 1.25 (95% CI: 1.04, 1.51) per natural log-unit increase, respectively. Risk of current asthma was > 70% higher among children with maternal prenatal BBzP and DnBP metabolite concentrations in the third versus the first tertile.Conclusion: Prenatal exposure to BBzP and DnBP may increase the risk of asthma among inner-city children. However, because this is the first such finding, results require replication.Citation: Whyatt RM, Perzanowski MS, Just AC, Rundle AG, Donohue KM, Calafat AM, Hoepner LA, Perera FP, Miller RL. 2014. Asthma in inner-city children at 5–11 years of age and prenatal exposure to phthalates: the Columbia Center for Children’s Environmental Health Cohort. Environ Health Perspect 122:1141–1146; http://dx.doi.org/10.1289/ehp.1307670     

Partners in school asthma management: evaluation of a self-management program for children with asthma

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.     

Agreement between responses to a standardized asthma questionnaire and a questionnaire following a demonstration of asthma symptoms in adults

Asthma epidemiology relies heavily on standardized questionnaires, but little is known about the understanding of asthma symptoms among adults in the community. In 2004, the authors assessed the level of agreement between responses to a standardized questionnaire and responses to a questionnaire completed by participants after viewing a demonstration of asthma symptoms. The study involved 601 young adults from Chile. The field-workers were trained to explain and demonstrate the asthma symptoms to the participants. The symptoms were wheeze, waking at night with breathlessness, breathlessness following exercise, and waking with cough. The kappa statistic did not exceed 0.4, and the recorded prevalence of asthma symptoms following the demonstration was 30-60% lower than that for the standardized questionnaire. Using bronchial responsiveness as the proxy gold standard, the positive likelihood ratios for wheeze and waking short of breath were higher following symptom demonstration. The low agreement between the standardized questionnaire and the postdemonstration questionnaire and the likelihood ratios' closeness to 1 for the standardized questionnaire decreases the authors' confidence in the appropriateness of this tool for estimating the prevalence of asthma in the community. For etiologic studies of asthma, it may contribute to the lack of consistency between different studies analyzing the same etiologic exposures.     

Asthma and wheezing symptoms in young people in six Western countries

BACKGROUND: Asthma diagnosed in children shows wide geographical variations. Large scale surveys identify children with diagnosed asthma, but neglect the group of youngsters with multiple asthmatic complaints. METHODS: A short validated asthma questionnaire was included in six national surveys of the Health Behaviour in School-Aged Children Study. Prevalence rates are presented by country, gender and age. Gender and age differences are analysed using binary and multinomial logistic regressions controlling for age and smoking. RESULTS: Large country differences are observed in the prevalence rates of diagnosed asthma (8.6%-20.9% in boys, 6.9%-18.5% in girls) and young people with "asthma-like symptoms" (9.6%-20.2% in boys, 9.2%-23.1% in girls). When controlling for age and smoking, significant gender differences are observed (more diagnosed asthma in boys, more asthmatic symptoms in girls). Age differences were observed in adolescents with "asthma-like symptoms", but not in diagnosed asthma. CONCLUSIONS: Using a short asthma questionnaire, large differences in diagnosed asthma and wheezing symptoms are observed between the countries. A considerable group of youngsters with "asthma-like symptoms" is detected in all countries, and may be an unrecognised risk group in health promotion.     

Pediatric asthma surveillance using Medicaid claims

OBJECTIVE: The purpose of this study was to describe the prevalence of asthma among children using alternative case definitions applied to administrative claims data, and to assess year-to-year classification concordance. METHODS: This study was a retrospective cohort analysis of 357,729 children 0-18 years using 2001-2002 Michigan Medicaid claims. Asthma cases were classified using six alternative definitions based on outpatient, emergency department, inpatient, and pharmacy claims for asthma, including the Health Plan Employer Data Information Set (HEDIS) persistent asthma criteria commonly used for assessments of asthma health care quality: at least one asthma inpatient admission or emergency department visit, four or more asthma medications events, or four asthma outpatient visits and two asthma medication events. RESULTS: Overall, asthma prevalence varied widely between alternative case definitions, ranging from 14.9% based on claims evidence of any type of asthma utilization to 3.7% when restricted to those with four or more asthma medication dispensing events. Among cases meeting HEDIS persistent asthma criteria in 2001, 55.5% met these criteria in 2002. Those with four or more asthma medication dispensing events had the best overall classification concordance between 2001 and 2002. Utilization of asthma services and prevalence estimates were highest among children younger than 5 years old, but year-to-year classification concordance was poorest among these cases (p < 0.0001), irrespective of case definition. CONCLUSIONS: While overall asthma prevalence may remain relatively stable from year to year, individuals may not be classified consistently as cases over time, regardless of case definition. Studies that identify asthma cases in one year and assess asthma outcomes in a subsequent year may introduce substantial bias as a result of case misclassification. Among the case definitions considered in this study, our findings suggest that this bias is minimized among cases classified using the four or more asthma medication dispensing events criterion.     

Population-Based Assessment of Asthma Symptom Burden in Children

The Minneapolis and St. Paul Controlling Asthma in American Cities Project (CAACP) used a school-based symptom survey to inform community-based programming and provide an intermediate outcome measure of progress toward reducing the burden of asthma. In collaboration with the two school districts, the project mailed the Child Asthma Short Form, a validated health-related quality of life instrument to parents of children in grades K–8 every other school year from 2003 to 2007. The survey was mailed to a randomly selected sample in four languages (English, Spanish, Hmong, and Somali). The overall response rate was 47%, 41%, and 32% for years 1, 3, and 5, respectively. Two out of three children for whom surveys were completed were children of minority populations; more than 50% were eligible for free or reduced-price meals. The changes in scores from the first round (2003–2004) to the third round (2007–2008) were statistically significant for daytime symptom burden (p?<?0.05). Improvements were noted, but not statistically significant, for nighttime symptoms and functional limitations. Children of some racial/ethnic minority groups and children eligible for free or reduced-price meals had the highest symptom burden. Findings were used to guide CAACP’s program development and delivery to populations in greatest need. CAACP’s experience in Minneapolis and St. Paul demonstrates the feasibility of administering a symptom burden survey at low cost and in compliance with school system and institutional review board requirements to maintain confidentiality. The symptom-based survey may be a useful tool to track trends and changes in health disparities at a community and population level.     

Is particle board in the home detrimental to health?

A questionnaire concerning health and living conditions was sent to the parents of 1387 children aged 0-15 years to answer the question if children living in homes built with large amounts of particle board had more headaches and respiratory and skin symptoms than other children. There were 1376 possible respondents, and of those 1036 (75.3)% returned the questionnaire. Of the questionnaires returned, 972 (70.6%) were analyzable. The children lived in homes with much particle board (group A); little particle board, or homes as group A but treated in a special way (group B); and homes with no particle board (group C). For the 0- to 5-year-old children, living in homes with much particle board was a risk factor for developing wheezy bronchitis, eye and nose irritation, and coughing. For the 6- to 15-year-old children, living in a home with much particle board was not a risk factor. Risk factors for headache, irritation of the throat, and need for daily antiasthmatic medication were analyzed for all the children collectively. Living in a home with much particle board was a risk factor for all three conditions.     

兰州市城区0～14岁儿童哮喘流行病学调查

目的了解兰州市城区0~14岁儿童哮喘患病率、发病规律及其诊治情况。方法采用多阶段分层随机整群抽样方法,向1996年7月1日零点-2010年7月1日零点出生的兰州市儿童或外地出生但在兰州居住和生活半年以上的儿童家长发放2010年第三次全国儿童哮喘流行病学调查统一问卷,筛查儿童哮喘及过敏疾病。筛查阳性儿童由临床医生明确哮喘诊断后做进一步问卷调查,了解其哮喘诊治情况及伴发过敏性疾病情况。所有数据使用Epi-Info3.5.3软件进行双录入,用SPSS 19.0进行统计分析。结果共抽取儿童11 068名,完成初筛问卷10 566份(95.46%)。共诊断哮喘298例2.82%,其中典型哮喘患病率2.51%(265/10 566)、咳嗽变异性哮喘患病率0.31%(33/10 566);54.36%(162/298)为既往已诊断哮喘;男性患病率3.31%(180/5 440),女性患病率2.30%(118/5 126)(χ2=9.761,P0.01)。不同发育阶段儿童以学龄前儿童(3~7岁)患病率最高为4.31%(116/2 690)。84.90%(253/298)的患儿近2年内仍存在哮喘症状,2年现患率为2.39%(253/10 566)。既往已诊断哮喘患儿中,按全球哮喘防治创议(Global Initiative for Asthma,GINA)方案使用过吸入激素的为87.65%(142/162),而抗生素的使用率高达87.04%(141/162)。结论兰州市城区0~14岁儿童哮喘总患病率较十年前明显增加,不同性别和不同年龄阶段儿童存在明显差异,仍有部分患儿未得到及时诊治,哮喘的管理水平亦亟待提高。     

Testing to Prevent Colon Cancer: Results From a Rural Community Intervention

PURPOSE

Colon cancer is the second leading cause of cancer death in the United States. Despite tests that can detect and enable removal of precancerous polyps, effectively preventing this disease, screening for colon cancer lags behind other cancer screening. The purpose of this study was to develop and test a community-based participatory approach to increase colon cancer screening.

METHODS

Using a community-based participatory research approach, the High Plains Research Network and their Community Advisory Council developed a multicomponent intervention—Testing to Prevent Colon Cancer—to increase colon cancer screening. A controlled trial compared 9 intervention counties in northeast Colorado with 7 control counties in southeast Colorado. We performed a baseline and postintervention random digit–dial telephone survey and conducted both intent-to-treat and on-treatment analyses.

RESULTS

In all, 1,050 community members completed a preintervention questionnaire and 1,048 completed a postintervention questionnaire. During the study period, there was a 5% absolute increase in the proportion of respondents who reported ever having had any test in the intervention region (from 76% to 81%) compared with no increase in the control region (77% at both time points) (P = .22). No significant differences between these groups were found in terms of being up to date generally or on specific tests. The extent of exposure to intervention materials was associated with a significant and cumulative increase in screening.

CONCLUSIONS

This community-based multicomponent intervention engaged hundreds of community members in wide dissemination aimed at increasing colorectal cancer screening. Although we did not find any statistically significant differences, the findings are consistent with an intervention-related increase in screening and provide preliminary evidence on the effectiveness of such interventions to improve colon cancer screening.     

What Drives Prescribing of Asthma Medication to Children? A Multilevel Population-Based Study

PURPOSE Diagnosing asthma in children with asthmatic symptoms remains a challenge, particularly in preschool children. This challenge creates an opportunity for variability in prescribing. The aim of our study was to investigate how and to what degree patient, family, and physician characteristics influence prescribing of asthma medication in children.     

Screening questionnaires for bakers' asthma--are they worth the effort?

The use of a respiratory screening questionnaire is recommendedannually to screen bakery workers in the UK. We compared questionnairescreening with other methods of detecting workers with asthmaticsymptoms and then assessed the significance of these symptomswith careful investigation and follow-up. Reasons for questionnairefailures were then explored. A questionnaire was issued to 362flour-exposed workers in a large bakery. All positive respondentsto respiratory symptom questions were interviewed by an occupationalnurse. Workers with occupationally related symptoms at thisinterview were referred to the chest clinic. In addition, workerswith negative questionnaires were screened using attendancerecords, sick notes and direct workplace observations. Workerswith frequent absence from work or sick notes with respiratorydiagnoses were interviewed in the same manner as those answeringthe questionnaire positively and then referred to clinic. Atclinic, a diagnosis was made for each worker on the basis ofclinical assessment, spirometry, serial peak expiratory flowrate (PEFR) analysis and radioallergosorbent testing (RAST)testing for specific IgE. Using the clinic diagnoses, the referralroutes were audited to assess the rates of case detection ofasthma and occupational asthma. The respiratory screening questionnaireidentified 68 workers with respiratory symptoms. Of these, 21proceeded to full assessment. A diagnosis of asthma was madein five cases, one of which was bakers' asthma. In addition,11 workers not reporting any symptoms by questionnaire werereferred to clinic and five were diagnosed as having asthma.Screening questionnaires may lead to an underestimate of theprevalence of asthmatic symptoms and as such should not be usedalone in workplace screening.     

Prevalence of childhood asthma in Baranya County, Hungary, between 2003 and 2006

INTRODUCTION: The prevalence of bronchial asthma, allergic rhinitis and atopic dermatitis (AD) in children has constantly and significantly increased worldwide in the past decades. Recent publications, however, reported a moderate decrease or levelling off in this parameter. The authors estimated the prevalence of bronchial asthma and asthmatic complaints among schoolchildren in Baranya county in the years 2003 and 2006 in order to register the possible changes. MATERIALS AND METHODS: Both surveys were carried out by means of identical questionnaires which were consistent with the ISAAC Phase III. protocol. The data were collected in 16 primary schools (6 in a city, 10 in small settlements and villages) in February 2006. Finally 2404 questionnaires (1124 boys, 1280 girls) in two age groups, among 6-7 and 13-14-year-old children were processed and compared to the data derived from the survey done in 2003. RESULTS: The prevalence of the "wheezing-ever" and "physician diagnosed asthma" did not change during the observation period (2006: 20.2% and 6.7%; 2003: 19.8% and 8.2%) but there was a significant increase in the frequency of "wheezing in the last 12 months" (2006: 9.6%; 2003: 6.8%). As expected, significantly higher prevalence rates were detected among boys and in the 6-7-year-old age group than among girls and in the 13-14-year-old age group in both surveys. There was no significant difference in the two surveys in the prevalence of bronchial asthma and asthmatic signs between children from a city and from small settlements. CONCLUSION: During the observation period of three years there was a significant increase "wheezing in the last 12 months", but the prevalence of "wheezing-ever" as well as the "physician-diagnosed asthma" remained unchanged.     

School-based Management of Chronic Asthma Among Inner-city African-American Schoolchildren in Dallas, Texas

ABSTRACT: Asthma, a chronic disease of the respiratory tract, affects approximately five percent of the U.S. population, including almost five million children. Childhood asthma has been identified as the leading cause of school absences. This study was to examined efficacy of a school-based program to prevent exacerbation of asthma symptoms and manage asthma in school children using measured doses of an inhaled anti-inflammatory medication. The sample consisted of 22 African-American children in one inner-city elementary school in Dallas, Texas, ages 5–12 years with confirmed diagnoses of asthma. For three months, each child came to the school clinic two times per day for medication administration and measurement of respiratory peak flow rates. Data were collected for a number of variables including bronchodilator use, school absences, self-report of asthma symptoms, and number of visits to the physician. During the study, mean peak flow rates improved approximately 15%, and bronchodilator use decreased 66%. Improvement also was evident in several other areas.     

Drawing from Freirian empowerment methods to develop and use innovative learning maps: increasing enrollment of uninsured children on Detroit's eastside

In 2001, virtually every child on Detroit's eastside was eligible for health coverage, yet approximately 3,000 children remained uninsured. The primary aim of the Eastside Access Partnership (EAP), a community-based participatory research collaboration, was to increase enrollment of uninsured children in state programs. To achieve this aim, one of the approaches that EAP is using is the innovative Learning Map titled Choosing the Healthy Path, which was developed in collaboration with Root Learning, Inc. Although Learning Maps were originally developed to assist corporations in implementing strategic change, their integration of visualization and interactive dialogue incorporates Freirian principles of empowerment education, making them a viable option for providing meaningful learning opportunities for community residents. This article presents the collaborative process involving the University of Michigan, local community-based organizations, community members, and Root Learning consultants to develop a visual map that enables community residents to understand and overcome the barriers that prevent them from obtaining health insurance for their children.